'A Most Protean Disease': Aligning Medical Knowledge of Modern Influenza, 1890-1914.

2012·3.3 MB·English

by  Bresalier, Michael

Med. Hist.,(2012),vol.56(4),pp.481–510. (cid:13)c TheAuthor2012.PublishedbyCambridgeUniversityPress
2012.TheonlineversionofthisarticleispublishedwithinanOpenAccessenvironmentsubjecttotheconditions
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doi:10.1017/mdh.2012.29
‘A Most Protean Disease’: Aligning Medical
Knowledge of Modern Influenza, 1890–1914
MICHAELBRESALIER∗
CentrefortheHistoryofScience,TechnologyandMedicine,SimonBuilding,BrunswickStreet,
UniversityofManchesterM139PL,UK
Abstract: This article reconstructs the process of defining influenza
as an infectious disease in the contexts of British medicine between
1890and1914.Itshowshowprofessionalagreementonitsnatureand
identity involved aligning different forms of knowledge produced in
the field (public health), in the clinic (metropolitan hospitals) and in
the laboratory (bacteriology). Two factors were crucial to this process:
increasingtrustinbacteriologyandtheorganisationoflarge-scalecol-
lectiveinvestigationsintoinfluenzabyBritain’scentralpublicauthority,
theMedicalDepartmentoftheLocalGovernmentBoard.Theseinvesti-
gationsintegratedepidemiological,clinicalandbacteriologicalevidence
into a new definition of influenza as a specific infection, in which a
germ – Bacillus influenzae – was determined as playing a necessary
but not sufficient role in its aetiology, transmission and pathogenesis.
Indefining‘moderninfluenza’,bacteriologicalconceptsandtechniques
were adapted to and selectively incorporated into existing clinical,
pathological and epidemiological approaches. Mutual alignment thus
wascrucialtoitsconstructionand,moregenerally,toshapingdevelop-
ingrelationshipsbetweenlaboratory,clinicalandpublichealthmedicine
in turn-of-the-century Britain. While these relationships were marked
by tension and conflict, they were also characterised by important
patternsofconvergence,inwhichtheproblems,interestsandpractices
of public health professionals, clinicians and laboratory pathologists
were made increasingly commensurable. Rather than retrospectively
judgethelatenineteenth-centurydefinitionofinfluenzaasbeingbased
on the wrong microbe, this article argues for the need to examine how
itwasestablishedthroughaparticularalignmentofmedicalknowledge,
which then underpinned medical approaches to the disease up to and
beyondthedevastating1918–19pandemic.
∗Emailaddressforcorrespondence:[email protected]
IamespeciallygratefultoMichaelWorboysandIanBurneyfortheirconstructivecriticismsandsuggestions.
Commentsfromtwoanonymousrefereeswereveryhelpful.AWellcomeTrustStrategicAward,heldbythe
CentrefortheHistoryofScience,TechnologyandMedicineattheUniversityofManchester,supportedthe
writingofthisarticle.
482 MichaelBresalier
‘[S]uch phrases as the return of influenza, the reimportation of influenza, etc., are
mere figures of speech; we have never lost it again since 1889’.1 So wrote the
Londonepidemiologist,MajorGreenwood.Likemanymedicalobservers,hewastrying
to contextualise the devastating 1918–19 pandemic. For Greenwood, the pandemic
representedtheculminationofa‘newcycle’ininfluenza’shistory,whichhadbegunwhen
three epidemics swept the globe between 1889 and 1894. His view was that through its
recorded history, influenza had appeared episodically, visiting Britain and Europe once
or twice a generation, until the 1890s, when it became ‘endemic’ in industrial nations.2
The epidemics inaugurated what Greenwood called the ‘modern period’ of influenza, as
itbecame‘afactorofgreatimportanceinthecausationofmortality’,andaninescapable
partofmodernlife.3
Greenwoodassumed,asdidmostofhiscontemporaries,thatthesigns,symptomsand
pathology of influenza had been essentially constant through history and that what had
changed since 1890 was the epidemiology of disease. In this article I show how, after
1889, medical practitioners were not simply mapping new behaviours of an old disease,
butthoseofanewinfluenza.Thisnewinfluenzawasconstructedprincipallywiththeideas
andtoolsofbacteriologyandtheirintegrationintoepidemiologicalandclinicalknowledge
and practices.4 Otto Leichtenstern, the Munich clinician and pathologist, explained this
transformation in his influential 1898 manuscript on influenza. The medical profession
across Europe, he noted, had confronted the pandemic as a ‘new disease’ and, by
applying‘theprogressandtheacquisitionsofmodernmedicine,advanced...knowledgeof
influenzaineverydirection’.5Nolongeraproductoftheair,atmosphereorcosmos,anew
definitionadheredto‘thedoctrineofthecontagiousnatureofinfluenza,ofitstransmission
frompersontoperson,anditsdisseminationthroughhumanintercourse’.6
This article reconstructs the process of defining ‘modern’ influenza in the contexts
of British medicine between 1890 and 1914. It shows how professional agreement on
its nature and identity involved aligning different forms of knowledge produced in
the field (public health), in the clinic (metropolitan hospitals) and in the laboratory
(bacteriology). While there existed different influenzas in the wake of the 1889–90
pandemic,theproblems,interestsandpracticesofpublichealthprofessionals,clinicians
andlaboratorypathologistsweremadeincreasinglycommensurable,suchthatbytheearly
1900sinfluenzawasgenerallycharacterisedasaspecificinfectiousdisease.
Examining this process provides particular insight into the developing relationships
between laboratory, clinical and public health medicine in Britain. Revisionist histories
of the adoption and use of laboratory knowledge and practices have demonstrated the
evolutionary rather than revolutionary nature of this process.7 However, as Steve Sturdy
1MajorGreenwood,‘Thehistoryofinfluenza,1658–1911’,inMinistryofHealthReportonthePandemicof
Influenza1918–19(London:HMSO,1920),3–30:20.
2Ibid.,23–4.
3MinistryofHealth,ReportonthePandemicofInfluenza,1918–19(London:HMSO,1920),vi.
4For the historiography and specific changes in Britain, see Michael Worboys, Spreading Germs: Disease
TheoriesandMedicalPracticeinBritain,1865–1900(Cambridge:CambridgeUniversityPress,2000),ch.1.
5OttoLeichtenstern,‘Influenza’,inJ.MannabergandO.Leichtenstern(eds),Malaria,InfluenzaandDengue
(PhiladelphiaandLondon:W.B.Saunders&Co,1905),523.
6Ibid.,523.
7Fortherevolutionarymodel,seeAndrewCunninghamandPerryWilliams(eds),TheLaboratoryRevolution
in Medicine (Cambridge: Cambridge University Press, 1992); Andrew Cunningham, ‘Transforming plague:
the laboratory and the identity of infectious disease’, in Andrew Cunningham and Perry Williams (eds),
idem,209–44.Fortheevolutionarymodel,seeChristopherLawrence,‘IncommunicableKnowledge:Science,
‘AMostProteanDisease’ 483
has recently argued, a strong tendency has been to examine this dynamic through the
prism of the ‘essential tension’ between medical practice and medical science.8 Conflict
has become the status quo ante in studies of the relations between the laboratory,
the clinic and the field, with each domain characterised as having distinctive, if not
incommensurable, institutional commitments, interests, values, skills, norms of practice
and evidence.9 Sturdy argues that a consequence of this focus is that other kinds of
negotiation, particularly those involving collaboration between laboratory and clinical
practitioners,havebeencastasexceptionalratherthanintrinsictothemakingofmodern
medicine.
While the conflict model has been dominant, recent historical work has pointed to
an important pattern of convergence, in which clinical and epidemiological knowledge
shaped and was shaped by laboratory knowledge.10 This pattern has been well
demonstratedfortheintegrationofbacteriologyintodifferentrealmsofmedicalpractice,
and its role in changing definitions of disease at the end of the nineteenth century.11
Michael Worboys and Christoph Gradmann have shown, respectively, for instance, that
to understand the redefinition of tuberculosis as a specific infectious disease in Britain
and Germany in the 1880s, it is necessary to examine how bacteriological concepts
and techniques were adapted into existing clinical, pathological and epidemiological
approaches.12 Their studies suggest that the transformation of tuberculosis’s identity
was the outcome of a process of mutual alignment and accommodation, in which
bacteriological,clinical,pathologicalandepidemiologicalapproachestothediseasewere
modified and made commensurable. Similar patterns have been identified in histories
TechnologyandtheClinicalArtinBritain,1850–1914’,JournalofContemporaryHistory,20(1985),503–20;
J.D.Howell,TechnologyandtheHospital:TransformingPatientCareintheEarlyTwentiethCentury(Baltimore:
Johns Hopkins University Press, 1995); Michael Worboys, ‘Was There a Bacteriological Revolution in Late
NineteenthCenturyMedicine?’,StudiesinHistoryandPhilosophyofBiologicalandBiomedicalSciences,38
(2007),20–42.
8SteveSturdy,‘LookingforTrouble:MedicalScienceandClinicalPracticeintheHistoriographyofModern
Medicine’,SocialHistoryofMedicine,24,3(2011),739–57.
9For an overview, see Morten Hammerborg, ‘The Laboratory and the Clinic Revisited: The Introduction of
LaboratoryMedicineintotheBergenGeneralHospital,Norway’,SocialHistoryofMedicine,24,3,(2011),
758–75.
10Olga Amsterdamska, ‘Chemistry in the clinic: the research career of Donald Dexter Van Slyke’,
in S. de Chadarevian and H. Kamminga (eds), Molecularizing Biology and Medicine: New Practices
and Alliances, 1910s–1970s (Amsterdam: Harwood Academic Publishers, 1998), 47–82. For general
approaches to aligning different medical knowledge, see I. Lo¨wy, ‘Medicine and change’, in I. Lo¨wy and
J.-P. Gaudillie`re (eds), Medicine and Change: Historical and Sociological Studies of Medical Innovation
(Montrouge, France: John Libbey Eurotext, 1993), 1–19; Marc Berg, ‘Turning a Practice into a Science:
Reconceptualizing Postwar Medical Practice’, Social Studies of Science, 25, 3 (1995), 437–76; M. Berg
andAnnemarieMol(eds),DifferencesinMedicine:UnravelingPractices,Techniques,andBodies(Durham:
Duke University Press, 1999); Annemarie Mol, ‘Pathology and the clinic: an ethnographic presentation
of two atheroscleroses’, in M. Lock, A. Young and A. Cambrosio (eds), Living and Working with
the New Medical Technologies. Intersections of Inquiry (Cambridge: University of Cambridge, 2000),
82–102.
11ThomasSchlich,‘LinkingCauseandDiseaseintheLaboratory:RobertKoch’sMethodofSuperimposing
Visual and Functional Representations of Bacteria’, HistoryandPhilosophyoftheLifeSciences, 22 (2000),
43–58;Worboys,op.cit.(note7).
12M.Worboys,‘Fromhereditytoinfection:tuberculosis,1870–1890’,inJ.-P.Gaudillie`reandI.Lo¨wy(eds),
HeredityandInfection:TheHistoryofDiseaseTransmission(London:Routledge,2001),81–100;Christoph
Gradmann, LaboratoryDisease:RobertKoch’sMedicalBacteriology (Baltimore: Johns Hopkins University
Press,2009).
484 MichaelBresalier
examining the relationship between the ‘bench’ and the ‘bedside’ in constructions of
cardiacdisease,13cancer,14aphasia15andallergy.16
Studying patterns of convergence and alignment between the different professions,
specialisms, disciplines, institutions and practices around which modern medicine has
been built can yield a more rounded and empirically rich picture of the dynamics of
producing medical knowledge, striking a balance between conflict and consensus. With
thisaiminview,thisarticleapproachestheprocessofdefininginfluenzainlatenineteenth-
centuryBritishmedicineasanexampleofhowaligningdifferentformsofknowledgewas
integral to creating the identity of a modern infectious disease. The first sections trace
the respective ways in which public health, clinical and bacteriological studies defined
influenzainthewakeofthe1889–90pandemic,stressinghoweachprovidedtheotherwith
conceptual and practical resources, and with specific problems to solve. The article then
examineshowevidencefromthesedifferentlinesofinvestigationwasdrawntogether,and
incorporatedandusedinpublichealth,clinicalmedicineandpathology.Increasingtrustin
bacteriologicalideasandmethodsinBritishmedicine,especiallyafter1900,wasacrucial
factor in this realignment. Another significant factor was the organisation of large-scale
collectiveinvestigationsbyBritain’scentralpublicauthority,theMedicalDepartmentof
the Local Government Board (LGB). These investigations integrated epidemiological,
clinical and bacteriological evidence into a new definition of influenza as a specific
infection,inwhichagerm–Bacillusinfluenzae–wasdeterminedasplayinganecessary
butnotsufficientroleinitsaetiology,transmissionandpathogenesis.Indefining‘modern
influenza’, bacteriological concepts and techniques were simultaneously adapted to and
incorporated into existing clinical, pathological and epidemiological frameworks. The
LGB was uniquely positioned to draw together such evidence and its relative success
in doing so demonstrates the importance of paying attention to mutual alignment in the
construction of a disease identity and, more generally, in the shaping of relationships
between laboratory, clinical and public health medicine in turn-of-the-century Britain.
While these relationships were certainly marked by tension and conflict, my analysis
showsthattheywerealsocharacterisedbyanimportantpatternofconvergenceinefforts
tomakesenseofahighlyproteandisease.
Historians of influenza know that its late nineteenth-century definition as a specific
infection was based on what was later shown to be the wrong microbe.17 Rather than
a bacillus, its primary causative agent is now identified as a virus. But, as I argue
below, retrospective diagnoses or judgements ignore the significance of the bacillus and
bacteriologyinredefininginfluenzaand,crucially,howbothfiguredintherealignmentof
clinicalandepidemiologicalknowledgeofthedisease.Thishistoryisespeciallyimportant
if we want to understand medical approaches to the 1918–19 pandemic in Britain and
13ChristopherLawrence,“‘Definiteandmaterial”:coronarythrombosisandcardiologistsinthe1920s’,inC.
RosenbergandJ.Golden(eds),FramingDisease:StudiesinCulturalHistory(NewJersey:RutgersUniversity
Press,1992),50–84.
14I.Lo¨wy,BetweenBenchandBedside:Science,HealingandInterleukin-2inaCancerWard(Cambridge,MA:
HarvardUniversityPress,1997).
15L.S. Jacyna, Lost Words: Narratives of Language and the Brain, 1825–1926 (Princeton, NJ: Princeton
UniversityPress,2000).
16Mark Jackson, “‘A private line to medicine”: the clinical and laboratory contours of allergy in the early
twentiethcentury’,inK.Kroker,J.KeelanandP.M.H.Mazumdar(eds),CraftingImmunity:WorkingHistories
ofClinicalImmunology(Aldershort:Ashgate,2008),55–76.
17E.Tognotti,‘ScientificTriumphalismandLearningfromFacts:Bacteriologyandthe“SpanishFlu”Challenge
of1918’,SocialHistoryofMedicine,16,1(2003),97–110.
‘AMostProteanDisease’ 485
elsewhere,preciselybecausetheywerebasedonthenewwaysofknowinginfluenzathat
wereforgedinthe1890sand1900s.Moregenerally,understandingtheprocessofdefining
moderninfluenzahighlightstheparticularimportanceofpayingattentiontoprocessesof
alignment and convergence in the production of medical knowledge at the turn of the
nineteenthcentury.
PublicHealth:MakingInfluenzaCommunicable
Throughmuchofthenineteenthcenturythediseasetermedinfluenzaplayedonlyaminor
role in the affairs of government, medicine, public health and everyday experience. It
existedonthefringesofVictorianlife.Londonmortalitystatisticstoldpartofthisstory.
From when ‘influenza’ was first used as a term in English medicine in the 1740s to the
1850s,epidemicshadvisitedLondonseventimes.18Largeepidemicsstruckin1782,1801,
1830–1, 1833 and 1847–8.19 But after 1848, influenza slipped off the epidemiological
map.Forthenextfourdecades,withtheexceptionofsmalloutbreaksin1855and1858,
itsprevalencesteadilydeclined.Between1870and1888ithadalmostdisappearedfrom
EnglandandtherestofEurope(Figure1).20
Thisperiodofdeclinecametoanabruptendinautumn1889,whenamassiveepidemic
sweptacrossEuropeandtherestoftheworld.Two‘recrudescences’,onelesswidespread
butmoredeadlyin1890–1andanotherin1892,followedthisepidemic.Influenzakilled
nofewerthan57980inBritainin1890and1891.Unlikeinthepast,however,itdidnot
abate.Innoyearbetween1890and1915didfewerthan496Londonersdiefromit;inten
of these years more than a thousand deaths were allotted to influenza. Major epidemics
struck London in 1895, 1899–1900 and 1908–9.21 In the decade thereafter, the number
ofdeathsaveraged11050peryear,andneverwentbelow3753(Figure2).22 Therestof
Europeasawholeexperiencedasimilarescalation.
Rawnumbersunderscoredinfluenza’schangingepidemiologicalpresenceinthesocial
experience of health and illness.23 But initially, while the epidemic was generally called
‘influenza’, neither public health professionals relying on epidemiological knowledge
nor medical practitioners relying on clinical knowledge could agree on its actual nature.
Agreement on its medical identity was the product of state-organised investigations that
mappedandredefineditsepidemiological,clinicalandaetiologicalcharacteristics.During
the1889–90epidemic,publichealthbodiesacrossEuropeorganisedlarge-scalestudiesof
influenza, with the general aim of resolving questions about its origins, causes, modes
18D.K.Patterson,PandemicInfluenza,1700–1900:AStudyinHistoricalEpidemiology(Totowa,NJ:Rowman
&Littlefield,1986).
19Ibid.,29–48.Forcontemporaryaccounts,seeC.Creighton,AHistoryofEpidemicsinBritain,Vol.II(London:
Cambridge University Press, 1894), 306–433 and Theophilus Thompson, Annals of Influenza or Epidemic
CatarrhalFeverinGreatBritainfrom1510–1837(London:TheSydenhamSociety,1852).
20From1861until1888,influenzadeathsinLondonwentabove50once(1864);inthe1870s,theyexceeded
25once(1870);from1880to1888,theyaveraged7.7peryear.Registrar-GeneralFifty-FourthAnnualReportof
theRegistrar-General,1891(London:HMSO,1892),xiii–iv.
21MinistryofHealth,op.cit.(note3),23.
22Sixty-thirdAnnualReportoftheRegistrarGeneral,1900,(London:HMSO,1902),ixvi.
23MinistryofHealth,op.cit.(note3),23–4.
486 MichaelBresalier
Figure1: Deathsfrominfluenza(London),1840–90.Source:H.F.Parsons,ReportontheInfluenzaEpidemicof
1889–1890(London:HMSO,1891).
‘AMostProteanDisease’ 487
674
533
504
500
460
423
400
389
325 320
300
285
223
220
200 193
195 189
157 174 168
120
100 92 99 93 122
73
78 76 68
58 55 57 45453931 3525
0 38 29 2914 1125111018888171434353332
0 0 0 0 0 0
5 6 7 8 9 0
8 8 8 8 8 9
1 1 1 1 1 1
Figure2: AnnualinfluenzadeathratepermillioninEnglandandWales,1847–1905.Source:A.Newsholme,
‘InfluenzaforthePublicHealthStandpoint’,ThePractitioner,LXXVII(1907),118.
of spread and what constituted a case of the disease. In Britain, the LGB’s Medical
Department produced two widely influential reports.24 Drawing on methods of case-
basedepidemiologyandtheepistemologicalresourcesofbacteriology,thesereportswere
widely heralded for producing a new way of understanding influenza. The first report,
published in 1891, demonstrated the Department’s leading role in the use of modern
epidemiological methods. The second, which we shall look at later, demonstrated their
increasing interaction with bacteriological knowledge, and the Department’s key role in
aligningepidemiological,clinicalandlaboratoryevidence.
The Department’s reputation for epidemiological investigations was well established
among European public health bodies.25 Before its investigations into influenza,
bacteriologyplayedagrowingroleintheproductionofepidemiologicalknowledgeand,
bythe1880s,theDepartmenthadtakenupbacteriologicalpracticesasastandardpartof
its‘AuxiliaryScientificInvestigations’intosuchdiseasesastyphus,diphtheria,smallpox,
scarlet fever and tuberculosis.26 As part of this new orientation, the Department’s focus
on ‘inclusive’ public health measures, guided by a sanitary vision and directed at the
environment, increasingly gave way to ‘exclusive’ measures, specifically directed at
24LocalGovernmentBoard,ReportontheInfluenzaEpidemicof1889–1890,Vol.XXXIV(London:HMSO,
1891); Local Government Board, Further Report and Papers on Epidemic Influenza, 1889–92, Vol. VLII
(London:HMSO,1893).
25A. Hardy, ‘On the Cusp: Epidemiology and Bacteriology at the Local Government Board, 1890–1905’,
MedicalHistory,42(1998),328–46:330–5.
26J.L.Brand,DoctorsandtheState:TheBritishMedicalProfessionandGovernmentActioninPublicHealth,
1870–1912(Baltimore:JohnsHopkinsPress,1965),73–5.
488 MichaelBresalier
Figure3: HenryFranklinParsons(1846–1913).Source:BMJ,8November(1913),1263.
diseaseagents,peopleandtheirinteractions.27Itsinvestigationsintoinfluenzaintheearly
1890swereimportanttotheprocessofintegratingthesechangesintoitsapproaches.
At the height of the epidemic in December 1889, the LGB’s Medical Officer,
GeorgeBuchanan,askedhisassistant,HenryFranklinParsons,toorganisea‘collective’
epidemiologicalinvestigation,withtheaimofdeterminingitsoriginsandmodesofspread
– issues that sharply divided medical observers (Figure 3). Harry Marks has shown
that collective investigations were first proposed by elite physicians in Britain as a way
to transcend the study of diseases in hospitals and to involve general practitioners in
reconstructingtheir‘life-history’throughpopulations.28Akeyaimwastostandardisethe
productionanduseofmedicalknowledge,particularlydiagnosticcategoriesandpractices.
While, as Marks suggests, the collective investigation had limited popularity as a tool
for clinical research, the basic principle of mobilising practitioners to study and to help
generate a standard picture of a disease was one that the Medical Department put into
practice in its own studies. Its style of collective inquiry, which it had already honed in
27Worboys,op.cit.(note4),234–76.
28‘Henry Franklin Parsons’, BMJ, 8 November (1913), 1263–64; ‘Henry Franklin Parsons’, Lancet, 18
November(1913),1355–56.Forcollectiveinvestigations,seeH.Marks,“‘UntiltheSunofScience...thetrue
ApolloofMedicinehasrisen”:CollectiveInvestigationinBritainandAmerica,1880–1910’,MedicalHistory,
50(2006),147–66.
‘AMostProteanDisease’ 489
Figure4: QuestionnaireontheOriginandspreadofinfluenza,1890.Influenzaisinscarequotes.Source:Henry
Parsons,ReportontheInfluenzaEpidemicof1889–1890(July1891),120.
investigationsofcholeraandsmallpox,involvedtheentirepublichealthsystem,gathering
informationfrommedicalofficers,GPsandothersourcesfromacrossthenationandmuch
oftheEmpire.29
In early January 1890, Parsons issued a questionnaire to collect information on
influenza on a ‘uniform plan’ (Figure 4). Case identification was key to determining
the first occurrence of influenza and when it became epidemic. But it depended on
29WilliamColeman,YellowFeverintheNorth:TheMethodsofEarlyEpidemiology(Madison:Universityof
WisconsinPress,1987),186.
490 MichaelBresalier
an agreed clinical definition. The problem for Parsons was that most practitioners
were unfamiliar with what constituted a case of influenza. While he provided a short
list of standard symptoms based on older classifications, as we shall see, these did
not match the ‘influenza’ practitioners actually encountered in 1889–90. Despite this
obstacle, Parson proceeded to gather opinions on the ‘commencement’, ‘the mode
of origin of introduction of the disease’, ‘its method of spread’ and ‘dissemination’
through households, communities and localities.30 He sent the questionnaire to 1777
sanitary districts, to all government departments and heads of public and quasi-public
bodies, medical and public health journals, and the daily press.31 Some 1150 reports
were returned. Parsons’ first impression on reviewing them was ‘bewilderment. There is
scarcelyasinglepropositionmadewhichwasnotcontradictedbydifferentobservers.’32
The avalanche of reports revealed deep fissures on crucial questions about the
influenza’s identity, the factors that caused the epidemic, how it spread and the speed it
travelled.Partoftheproblemstemmedfromtheepidemiologicalcomplexityofthedisease
itself. Influenza’s ‘mode of diffusion stands almost alone among epidemic diseases’, the
Lancet noted:
Inthefirstplace,itspreadswithremarkablerapidityonceitisestablishedinacentre.Secondly,ittends
moreorlessrapidlytobecomepandemic...itsliabilitytodiffusionoverwholecontinents,andindeed
fromonehemispheretotheother,isoneofthebest-knownfactsconcerningit.Thediseasethereforehasno
geographicallimitation...anditsvirustravelsoverseasandlandinmannersobafflingandcontradictory
to the ordinary conceptions of the transmission of infection as to render any simple explanation of its
naturealmostimpossible.33
But disputes over influenza’s epidemiology, and efforts to decide its clinical
characteristics,werealsorootedincompetingmedicalepistemologies.
A priority for public health professionals was to explain how influenza had spread
so rapidly and appeared so suddenly. At first, disagreement reigned. Some observers
invoked theories based on the original meaning of ‘influenza’, which presupposed an
external influence – occult, telluric, astral or meteorological – that conspired to excite
an epidemic.34 The notion of an ‘epidemic constitution’, which was traced back to
the seventeenth-century writings of the ‘English Hippocrates’, Thomas Sydenham, was
widelyusedtoarguethattheepidemicwastheproductofoneoranumberofchangesin
temperature,moisture,airpressure,ozonelevelsandthenatureanddensityoffogs.35 A
longhistoryofassociatinginfluenzawiththeweatherhadwideappealbecauseitresonated
withpopularperceptionsofitsapparentaffinityforcolderanddampermonthsoftheyear.
Reports in the general press attributed the epidemic to miasmas activated by elemental
forces,suchasfloods,droughts,earthquakes,volcanoesorelectricalmagneticwaves.36
Historianshavefocusedonrivalriesinepidemiologicalthinkingbetweensupportersof
miasmatic and contagion theories, but, as Pelling has shown, in practice the dominant
30H.F.Parsons,LocalGovernmentBoard,ReportontheInfluenzaEpidemicof1889–1890(London:HMSO,
1891),120.
31Ibid.,13.
32F.Clemow,‘EpidemicInfluenza’,PublicHealth,24(1890),358–66.
33Lancet,21December1889,1293.
34M.DeLacy,‘TheConceptualizationofInfluenzainEighteenthCenturyBritain:SpecificityandContagion’,
BulletinoftheHistoryofMedicine,67,1(1993),74–118.
35E.S.Thompson,‘‘Influenza,orEpidemicCatarrhalFever:AnHistoricalSurveyofPast’’,EpidemicsinGreat
Britainfrom1510to1890(London:Percival&Co.,1890),17–23.
36SeeF.B.Smith,‘TheRussianInfluenzaintheUnitedKingdom’,SocialHistoryofMedicine,8,1(1995),62.